Design

Setting

Patients

562 consecutive, newly admitted patients who had not resided in nursing homes in the
6 months before their admission to the study facilities were eligible. 454 (81%) were
enrolled and 14 patients (3%) were lost to follow-up. 61% of patients were between
65 and 84 years of age and 35% were older, 94% were white, and 77% were women.

Assessment of prognostic factors

Psychiatric examination included a semistructured clinical examination (Modified Present
State Examination) and the Mini-Mental State Examination. Agreement on psychiatric
diagnosis (according to American Psychiatric Association criteria) made by 3 psychiatrists
on 8 patients was 89% above chance agreement (P < 0.001). Information on each patient's activities of daily living was obtained
from independent interviews with patients (if possible), nursing staff, and family
members. Demographic information and nursing home physicians' diagnoses at admission
were obtained from records. Medical severity was estimated from the presence of immobility,
incontinence, or pressure sores; hospitalization during the year; and the number of
medical diagnoses at admission.

Main outcome measure

All-cause mortality.

Main results

67% of patients were demented at admission. 57 patients (13%) had depressive disorder,
82 patients (18%) had depressive symptoms, and 315 patients (69%) had no depression.
Patients with depressive disorder and depressive symptoms were less often demented
(P < 0.05), had higher cognitive function (P < 0.001), and were more capable of doing activities of daily living (P < 0.05). The recognition rate of depressive disorder was 14% and 65% for physicians
and nurses, respectively; for depressive symptoms, it was 14% and 54%, respectively.

Commentary

Depression is a treatable and potentially reversible condition. It produces morbidity
and affects prognosis by compromising the person's motivation to overcome or adapt
to the functional limitations imposed by illness. Rovner and colleagues showed the
high prevalence of depression that exists among nursing-home patients and its significant,
independent, adverse effect on survival. Depression is also common among hospitalized
older patients and is associated with greater in-hospital mortality and a greater
use of health care by those who did not die (1). The study by Rovner and colleagues also documents the disturbingly common failure
of physicians to recognize depression. In one study of elderly outpatients, the likelihood
of a geriatric fellow's clinical impression agreeing with a standardized depression
screen was no better than chance (2). The results of the present study underscore the need for primary care physicians
to systematically screen their elderly patients for depression, especially in high-prevalence
settings such as nursing homes.

Whether depressed nursing-home patients will benefit from antidepressant therapy is
unclear. The authors found no difference in survival among patients with depressive
disorder who received or did not receive antidepressants, but the numbers were small
and the types of medication used were not given. Because various comparatively safe
and effective treatment modalities exist, physicians should not be reluctant to treat
depression in nursing-home patients, including "situational depression," when the
situation is permanent.